preconceptional planning, pregnancy and travel
factors affecting the decision to travel before and during pregnancy reproductive-aged women who may be planning both pregnancy and international travel should consider preconceptional immunisation, when practical, to prevent disease in the offspring. since as many as 50% of pregnancies are unplanned, reproductive-aged women should consider maintaining current immunisations during routine check-ups in case of an unplanned pregnancy and a need to travel. preconceptional immunisations are preferred to vaccination of pregnant women, because they decrease risk to the unborn child. a woman should defer pregnancy for at least 28 days after receiving live vaccines (e.g., mmr, yellow fever), because of theoretical risk of transmission to the foetus. vaccination of susceptible women during the postpartum period, especially for rubella and varicella, is another opportunity for prevention, and these vaccines should be encouraged and administered (even for breastfeeding mothers) before discharge from the hospital. for women taking malarial prophylactic medications in anticipation of travel, no data link these medications to congenital malformations, so cdc does not recommend that women planning pregnancy need to wait a specific period of time after their use before becoming pregnant. pregnant women considering international travel should be advised to evaluate the potential problems associated with international travel as well as the quality of medical care available at the destination and during transit. according to the american college of obstetrics and gynecology, the safest time for a pregnant woman to travel is during the second trimester (18-24 weeks), when she usually feels best and is in least danger of spontaneous abortion or premature labour. a woman in the third trimester should be advised to stay within 300 miles of home because of concerns about access to medical care in case of problems such as hypertension, phlebitis, or premature labour. pregnant women should be advised to consult with their health-care providers before making any travel decisions. collaboration between travel health experts and obstetricians is helpful in weighing benefits and risks based on destination and recommended preventive and treatment measures. table 9-2 lists relative contraindications to international travel during pregnancy. in general, pregnant women with serious underlying illnesses should be advised not to travel to developing countries. table 9-2. potential contraindications to international travel during pregnancy obstetrical risk factors general medical risk factors travel to potentially hazardous destinations history of miscarriage incompetent cervix history of ectopic pregnancy (ectopic with current pregnancy should be ruled out before travel) history of premature labour or premature rupture of membranes history of or existing placental abnormalities threatened abortion or vaginal bleeding during current pregnancy multiple gestation in current pregnancy foetal growth abnormalities history of toxemia, hypertension, or diabetes with any pregnancy primigravida at 35 years of age or 15 years of age history of thromboembolic disease pulmonary hypertension severe asthma or other chronic lung disease valvular heart disease (if nyha class iii or iv heart failure) cardiomyopathy hypertension diabetes renal insufficiency severe anaemia or haemoglobinopathy chronic organ system dysfunction requiring frequent medical interventions high altitudes areas endemic for or with ongoing outbreaks of life-threatening food- or insect-borne infections areas where chloroquine-resistant p. falciparum malaria is endemic areas where live-virus vaccines are required and recommended preparation for travel during pregnancy once a pregnant woman has decided to travel, a number of issues need to be considered before her departure. an intrauterine pregnancy should be confirmed by a clinician and ectopic pregnancy excluded before beginning any travel. health insurance should provide coverage while abroad and during pregnancy. in addition, a supplemental travel insurance policy and a prepaid medical evacuation insurance policy should be obtained, although most may not cover pregnancy-related problems. check medical facilities at her destination. for a woman in the last trimester, medical facilities should be able to manage complications of pregnancy, toxemia, and cesarean sections. determine beforehand whether prenatal care will be required abroad and, if so, who will provide it. the pregnant traveller should also make sure prenatal visits requiring specific timing are not missed. determine, before travelling, whether blood is screened for hiv and hepatitis b at the destination. the pregnant traveller should also be advised to know her blood type, and rh-negative pregnant women should receive the anti-d immune globulin (a plasma-derived product) prophylactically at about 28 weeks' gestation. the immune globulin dose should be repeated after delivery if the infant is rh-positive. general recommendations for travel a pregnant woman should be advised to travel with at least one companion; she should also be advised that, during her pregnancy, her level of comfort may be adversely affected by travelling. typical problems of pregnant travellers are the same as those experienced by any pregnant woman: fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased frequency of urination, and haemorrhoids. preventive measures including avoidance of gas-producing food or drinks before scheduled flights (entrapped gases can expand at higher altitudes) and periodic movement of the legs (to decrease venous stasis) can be followed by pregnant women during travel. however, pregnant women should continuously use seatbelts while seated, as air turbulence is not predictable and may cause significant trauma. signs and symptoms that indicate the need for immediate medical attention are bleeding, passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual problems. greatest risks for pregnant travellers motor vehicle accidents are a major cause of morbidity and mortality for pregnant women. when available, safety belts should be fastened at the pelvic area. lap and shoulder restraints are best; in most accidents, the foetus recovers quickly from the safety belt pressure. however, even after seemingly mild blunt trauma, a physician should be consulted. hepatitis e (see chapter 4), which is not vaccine preventable, can be especially dangerous for pregnant women, for whom the case-fatality rate is 17%-33%. therefore, pregnant women should be advised that the best preventive measures are to avoid potentially contaminated water and food, as with other enteric infections. scuba diving at any depth should be avoided in pregnancy because of the risk of decompression syndrome in the foetus. specific recommendations for pregnancy and travel air travel during pregnancy commercial air travel poses no special risks to a healthy pregnant woman or her foetus. the american college of obstetricians and gynaecologists (acog) states that women (with healthy, single pregnancies) can fly safely up to 36 weeks' gestation. the lowered cabin pressures (kept at the equivalent of 1,524-2,438 meters [5,000-8,000 feet]) affect foetal oxygenation minimally because of the favorable foetal haemoglobin-oxygen dynamics. if required for some medical indications, supplemental oxygen can be ordered in advance. severe anaemia, sickle-cell disease or trait, or history of thrombophlebitis are relative contraindications to flying. pregnant women with placental abnormalities or risks for premature labour should avoid air travel. each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking reservations, because some will require medical forms to be completed. domestic travel is usually permitted until the pregnant traveller is in her 36th week of gestation, and international travel may be permitted until weeks 32-35, depending on the airline. a pregnant woman should be advised always to carry documentation stating her current gestational age and expected date of delivery. airport security radiation exposure is minimal for pregnant women and has not been linked to an increase in adverse outcomes for unborn children to date. however, because of early reports of a possible association of radiation exposure during pregnancy and subsequent increased risk of childhood leukemia and cancer, a pregnant passenger may request a hand or wand search rather than being exposed to the radiation of the airport security machines. an aisle seat at the bulkhead will provide the most space and comfort, but a seat over the wing in the midplane region will give the smoothest ride. a pregnant woman should be advised to walk every half hour during a smooth flight and flex and extend her ankles frequently to prevent phlebitis. the safety belt should always be fastened at the pelvic level. dehydration can lead to decreased placental blood flow and haemoconcentration, increasing risk of thrombosis. thus, pregnant women should drink plenty of fluids during flights. for flight attendants and pilots, working air travel is restricted by most airlines by 20 weeks' gestation. travel to high altitudes during pregnancy acclimatization responses at altitude act to preserve foetal oxygen supply, but all pregnant women should avoid altitudes >3,658 meters (>12,000 feet). in addition, altitudes >2,500 meters (>8,200 feet) should be avoided in late or high-risk pregnancy. pregnant air travellers with medical problems that may be exacerbated by a hypoxic, high-altitude environment but who must travel by air should be prescribed supplemental oxygen during air travel. all pregnant women who have travel to high altitude should postpone exercise until acclimatized. food- and waterborne illness during pregnancy pregnant travellers should be advised to exercise dietary vigilance while travelling because dehydration from travellers' diarrhoea can lead to inadequate placental blood flow and increased risk for premature labour. suspect drinking water should be boiled to avoid long-term use of iodine-containing purification systems. iodine tablets can probably be used for travel up to several weeks, but congenital goiters have been reported in association with administration of iodine-containing drugs during pregnancy. pregnant travellers should eat only well-cooked meats and pasteurized dairy products, while avoiding pre-prepared salads; this will help to avoid diarrhoeal disease as well as infections such as toxoplasmosis and listeria, which can have serious sequelae in pregnancy. oral rehydration is the mainstay of therapy for travellers' diarrhoea. bismuth subsalicylate compounds are contraindicated because of the theoretical risks of foetal bleeding from salicylates and teratogenicity from the bismuth. the combination of kaolin and pectin may be used, and loperamide should be used only when necessary. the antibiotic treatment of travellers' diarrhoea during pregnancy can be complicated. azithromycin or an oral third-generation cephalosporin may be the best options for treatment if an antibiotic is needed. malaria during pregnancy malaria in pregnancy carries significant morbidity and mortality for both the mother and the foetus. pregnant women should be advised to avoid travel to malaria-endemic areas if possible. women who do choose to go to malarious areas can reduce their risk of acquiring malaria by following several preventive approaches, including personal protection to avoid infective mosquito bites and using prophylactic malaria medication as directed. because no preventive method is 100% effective, they should seek care promptly if symptoms of malaria develop. pregnant women travelling to malarious areas should 1) remain indoors between dusk and dawn, if mosquitoes are active outdoors during this time; 2) if outdoors at night, wear light-colored clothing, long sleeves, long pants, and shoes and socks; 3) stay in well-constructed housing with air-conditioning and/or screens; 4) use permethrin-impregnated bed nets; and 5) use insect repellents containing deet as recommended for adults, sparingly, but as needed. (see also "protection against mosquitoes and other arthropods".) pyrethrum-containing house sprays may also be used indoors if insects are a problem. if possible, remaining in cities or areas of cities that are at low (or lower) risk for malaria can help reduce the chances of infection. pregnant travellers should be under the care of providers knowledgeable in the care of pregnant women in tropical areas. for pregnant women who travel to areas with chloroquine-sensitive plasmodium falciparum malaria, chloroquine has been used for malaria chemoprophylaxis for decades with no documented increase in birth defects. for pregnant women who travel to areas with chloroquine-resistant p. falciparum, mefloquine should be recommended for chemoprophylaxis during the second and third trimesters. for women in their first trimester, most evidence suggests that mefloquine prophylaxis causes no significant increase in spontaneous abortions or congenital malformations if taken during this period. (also see section "chemoprophylaxis during pregnancy," in the malaria section, chapter 4.) because there is no evidence that chloroquine and mefloquine are associated with congenital defects when used for prophylaxis, cdc does not recommend that women planning pregnancy need to wait a specific period of time after their use before becoming pregnant. however, if women or their health-care providers wish to decrease the amount of antimalarial drug in the body before conception, table 9-3 provides information on the half-lives of selected antimalarial drugs. after 2, 4, and 6 half-lives, approximately 25%, 6%, and 2% of the drug remain in the body. table 9-3. half-lives of selected antimalarial drugs drug half life atovaquone 2-3 days chloroquine can extend from 6 to 60 days doxycycline 12-24 hours mefloquine 2-3 weeks primaquine 4-7 hours proguanil 14-21 hours pyrimethamine 80-95 hours sulfadoxine 150-200 hours avoidance of insects during pregnancy like malaria, other vector-borne illnesses may be more severe in pregnancy, bear potential harm to the foetus, or both. pregnant travellers should scrupulously avoid insects by wearing clothing that covers most of the body, bed nets, permethrin treatment for clothing and nets, and application of deet-containing repellents. (see also "protection against mosquitoes and other arthropods".) the recommendations for deet use in pregnant women do not differ from those for nonpregnant adults. women choosing lower concentrations of deet must increase the frequency of application if staying outdoors for long periods. malaria must be treated as a medical emergency in any pregnant returning traveller. a woman who has traveled to an area that has chloroquine-resistant strains of p. falciparum should be treated as if she has illness caused by chloroquine-resistant organisms. because of the serious nature of malaria, quinine or intravenous quinidine should be initiated and the case should be managed in consultation with an infectious disease or tropical medicine specialist. the management of malaria in a pregnant woman should include frequent blood glucose determinations and careful fluid monitoring: these requirements may necessitate intensive care supervision. immunisations risk to a developing foetus from vaccination of the mother during pregnancy is primarily theoretical. no evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. the benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or foetus, and when the vaccine is unlikely to cause harm. pregnant women should be advised to avoid live-virus vaccines (measles, mumps, rubella, varicella and yellow fever). women should also avoid becoming pregnant within 1 month of having received one of these vaccines because of theoretical risk of transmission to the foetus. however, no harm to the foetus has been reported from the unintentional administration of these vaccines during pregnancy. table 9-4 summarizes use of each vaccine in pregnancy. table 9-4. vaccination during pregnancy vaccine/immunobiologic use immune globulins, pooled or hyperimmune immune globulin or specific globulin preparations if indicated for pre- or post-exposure use. no known risk to foetus. diphtheria-tetanus toxoid if indicated, such as lack of primary series, or no booster within past 10 years. hepatitis a inactivated virus data on safety in pregnancy are not available; the theoretical risk of vaccination should be weighed against the risk of disease. consider immune globulin rather than vaccine. hepatitis b recombinant or plasma-derived recommended for women at risk of infection. influenza inactivated whole virus or subunit all women who are pregnant in the second and third trimesters during the flu season; women at high risk for pulmonary complications, regardless of trimester. japanese encephalitis inactivated virus data on safety in pregnancy are not available; the theoretical risk of vaccination should be weighed against the risk of disease. measles live attenuated virus contraindicated; vaccination of susceptible women should be part of postpartum care. meningococcal meningitis polysaccharide indications for prophylaxis not altered by pregnancy; vaccine recommended in unusual outbreak situations. mumps live attenuated virus contraindicated; vaccination of susceptible women should be part of postpartum care. pneumococcal polysaccharide indications not altered by pregnancy. polio, inactivated inactivated virus indicated for susceptible pregnant women travelling in endemic areas or in other high-risk situations. rabies inactivated virus indications for prophylaxis not altered by pregnancy; each case considered individually. rubella live attenuated virus contraindicated; vaccination of susceptible women should be part of postpartum care. tuberculosis (bcg) attenuated mycobacterial contraindicated. typhoid (vicps) polysaccharide if indicated for travel to endemic areas. typhoid (ty21a) live bacterial data on safety in pregnancy are not available. varicella live attenuated virus contraindicated; vaccination of susceptible women should be considered postpartum. yellow fever live attenuated virus indicated if exposure cannot be avoided. postponement of travel preferable to vaccination, if possible. routine and travel-related immunisations for pregnant women ideally, all reproductive-aged women should be up to date on their routine immunisations, whether or not they are planning a pregnancy. therefore, in the event of an unplanned pregnancy, most women would be prepared if international travel were needed. the following information is intended for women who may require immunisations during pregnancy. pregnant travellers may visit areas of the world where diseases eliminated by routine vaccination in the united states are still endemic and therefore, may require immunisations before travel. bacille calmette-gurin (bcg) bcg vaccine, used outside the united states for the prevention of tuberculosis, can theoretically cause disseminated disease and thus affect the foetus. although no harmful effects to the foetus have been associated with bcg vaccine, its use is not routinely recommended for u.s. travellers. skin testing for tuberculosis exposure before and after travel is preferable when the risk is high. diphtheria-tetanus the combination diphtheria-tetanus immunisation should be given if the pregnant traveller has not been immunised within 10 years, although preference would be for its administration during the second or third trimester. hepatitis a pregnant women without immunity to hepatitis a virus (hav) need protection before travelling to developing countries. hav is usually no more severe during pregnancy than at other times and does not affect the outcome of pregnancy. there have been reports, however, of acute fulminant disease in pregnant women during the third trimester, when there is also an increased risk of premature labour and foetal death. these events have occurred in women from developing countries and might have been related to underlying malnutrition. hav is rarely transmitted to the foetus, but this can occur during viremia or from faecal contamination at delivery. immune globulin (ig) is a safe and effective means of preventing hav, but immunisation with one of the hav vaccines gives a more complete and prolonged protection. the effect of these inactivated virus vaccines on foetal development is unknown and is expected to be low; the production methods for the vaccines are similar to that for ipv, which is considered safe during pregnancy. hepatitis b the hepatitis b vaccine may be administered during pregnancy and is recommended for pregnant women at risk for hepatitis b virus infection. exposed newborns need to be vaccinated and receive immune globulin as soon as possible. immune globulin preparations no known foetal risk exists from passive immunisation of pregnant women with immune globulin preparations. administration of ig can be used pre-exposure as protection against hepatitis a or for postexposure management for other viral diseases if warranted. influenza because of the increased risk for influenza-related complications, women who will be beyond the first trimester of pregnancy (>14 weeks gestation) during the influenza season of their travel destination should be vaccinated, when vaccine is available. further, those with chronic diseases that increase their risk of influenza-related complications should be vaccinated, regardless of gestational dates. data from influenza immunisation of >2,000 pregnant women have not demonstrated an association with adverse foetal effects. japanese encephalitis no information is available on the safety of japanese encephalitis vaccine during pregnancy. it should not be routinely administered during pregnancy, except when a woman must stay in a high-risk area. if not mandatory, travel to such areas should be postponed until after delivery and until the infant is old enough to be safely vaccinated (1 year). measles, mumps, and rubella the measles vaccine, as well as the measles, mumps, and rubella (mmr) vaccines in combination, are live-virus vaccines and so they are contraindicated in pregnancy. however, in cases in which the rubella vaccine was unintentionally administered, no complications have been reported. because of the increased incidence of measles in children in developing countries and because of the disease's communicability and its potential for causing serious consequences in adults, susceptible women should delay travelling until after delivery, when immunisation can be given safely. if an unprotected (without a history of physician-diagnosed measles or without at least two doses of measles vaccine) pregnant woman has a documented exposure to measles, ig should be given within 6 days to prevent illness. meningococcal meningitis the polyvalent meningococcal meningitis vaccine can be administered during pregnancy if the woman is entering an area where the disease is epidemic. studies of vaccination during pregnancy have not documented adverse effects among either pregnant women or neonates and have shown the vaccine to be efficacious. based on data from studies involving the use of meningococcal vaccines administered during pregnancy, altering meningococcal vaccination recommendations during pregnancy is unnecessary. pneumococcal (ppv23) the safety of pneumococcal polysaccharide vaccine during the first trimester of pregnancy has not been evaluated, although no adverse foetal consequences have been reported after inadvertent vaccination during pregnancy. women with chronic diseases (such as asplenia, or metabolic, renal, cardiac, or pulmonary diseases), smokers, and immunosuppressed women should consider vaccination. poliomyelitis the pregnant traveller must be protected against poliomyelitis. paralytic disease can occur with greater frequency when infection develops during pregnancy. anoxic foetal damage has also been reported, with up to 50% mortality in neonatal infection. if not previously immunised, a pregnant woman travelling to an area where polio still occurs should be advised to have at least two doses of vaccine one month apart before departure. there is no convincing evidence of adverse effects of inactivated poliovirus vaccine in pregnant women or developing foetuses. however, it is prudent to avoid polio vaccination of pregnant women unless immediate protection is needed. rabies because of the potential consequences of inadequately treated rabies exposure and because there is no indication that foetal abnormalities have been associated with cell culture rabies vaccines, pregnancy is not considered a contraindication to rabies postexposure prophylaxis. if the risk of exposure to rabies is substantial, preexposure prophylaxis may also be indicated during pregnancy. typhoid no data are available on the use of either typhoid vaccine in pregnancy. the vi capsular polysaccharide vaccine (vicps) injectable preparation is the vaccine of choice during pregnancy because it is inactivated and requires only one injection. the oral ty21a typhoid vaccine is not absolutely contraindicated during pregnancy, but it is live-attenuated and thus has theoretical risk. with either of these, the vaccine efficacy (about 70%) needs to be weighed against the risk of disease. varicella women who are pregnant or planning to become pregnant should not receive the varicella vaccine. nonimmune pregnant women should consider postponing travel until after delivery when the vaccine can be given safely. varicella zoster immune globulin (vzig) should be strongly considered within 96 hours of exposure for susceptible, pregnant women who have been exposed. however, vzig may not be readily available overseas. yellow fever the safety of yellow fever vaccination during pregnancy has not been established, and the vaccine should be administered to a pregnant woman only if travel to an endemic area is unavoidable and if an increased risk for exposure exists. in these instances, the vaccine can be administered, and infants born to these women should be monitored closely for evidence of congenital infection and other possible adverse effects resulting from yellow fever vaccination. although concerns exist, no congenital abnormalities have been reported after administration of this vaccine to pregnant women. further, serologic testing to document an immune response to the vaccine can be considered, because the seroconversion rate for pregnant women may be lower than in other healthy adults. if travelling to or transiting regions within a country where the disease is not a current threat but where policy requires a yellow fever vaccination certificate, pregnant travellers should be advised to carry a physician's waiver, along with documentation (of the waiver) on the immunisation record. in general, pregnant women should be advised to postpone travel to areas where yellow fever is a risk until after delivery, when vaccine can be administered to the mother without concern of foetal toxicity. travellers with infants <9 months of age should be strongly advised against travelling to areas within the yellow fever-endemic zone (see chapter 4, yellow fever section). the travel health kit during pregnancy additions and substitutions to the usual travel health kit need to be made during pregnancy. talcum powder, a thermometer, ors packets, prenatal vitamins, an antifungal agent for vaginal yeast, paracetamol (acetaminophen in usa) (paracetamol), and a sunscreen with a high spf should be carried. women in the third trimester may be advised to carry a blood-pressure cuff and urine dipsticks so they can check for proteinuria and glucosuria, both of which would require prompt medical attention. antimalarial and antidiarrhoeal self-treatment medications should be evaluated individually, depending on the traveller, her gestational age, itinerary, and her health history. most medications should be avoided, if possible. bibliography american college of obstetricians and gynaecologists. acog committee opinion no. 282. immunisation during pregnancy. obstet gynecol. 2003;101:207-12. american college of obstetricians and gynaecologists. acog committee opinion no. 264. air travel during pregnancy. obstet gynecol. 2001;98:1187-8. barish rj. in-flight radiation exposure during pregnancy. obstet gynecol. 2004;103:1326-30. bia fj. medical considerations for the pregnant traveller. infect dis clin north am. 1992;6:371-88. bocie jd jr., miller rw. childhood and adult cancer after intrauterine exposure to ionizing radiation. teratology. 1999;59:227-33.Relaterede Sundhed Artikler
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